The accuracy of axillary staging and of pathologic evaluation of clinically node-positive breast cancer is improved by a new procedure. This reduces the need for a more invasive procedure with debilitating complications, according to the report in the Journal of Clinical Oncology (doi:10.1200/JCO.2015.64.0094).

The sentinel lymph nodes and additional cancerous lymph nodes found during diagnosis are removed during targeted axillary dissection (TAD). At the time of diagnosis, those nodes are clipped for identification during later surgery. TAD is now the standard procedure for breast cancer patients with lymph node metastasis at MD Anderson Cancer, Houston, Texas, where the research was done.

Axillary metastasis is found in more than 60 000 women with breast cancer each year, and complete axillary lymph node dissection (ALND) has been the standard of care until recently. Recovery from ALND is challenging and can have lifelong effects. Abigail Caudle, MD, assistant professor, Breast Surgical Oncology at MD Anderson, and first author in the study, explained that patients can experience complications such as numbness and lymphedema.

Notably, administering chemotherapy before surgery results in approximately 40% of patients with axillary metastasis having no evidence of disease in their lymph nodes. Thus, these patients would not need the invasive surgery to remove lymph nodes.

"As chemotherapy is utilized more often before surgery, there is a greater likelihood that the disease in the lymph nodes will be eradicated and surgeons do not need to perform extensive nodal surgery," explained Caudle. She also stated that the challenge is for surgeons to identify which patients have had this nodal change from the chemotherapy.

"We just haven't had a good way to determine which patients have converted to node-negative status, and thereby, we are subjecting too many women to unnecessary surgery," said Caudle. "With our study, we hoped to find a new way to target the lymph node known to have cancer, selectively remove it, look at it, and hopefully avoid additional surgery if chemotherapy has wiped out all the cancer."

This prospective single-institution study enrolled 208 patients with breast cancer and axillary metastasis. When these patients underwent their first ultrasound and biopsy, radiologists placed a clip in the cancerous node. The patients were treated with chemotherapy. The day before surgery, small radioactive seeds were implanted in the clipped node to help locate them, then pathologists examined the specific pathology of the clipped node to see how it related to other nodes.

"This study may now allow up to 40% of women who are diagnosed with axillary metastasis and undergo neoadjuvant chemotherapy to avoid more extensive and often debilitating surgery," said Henry Kuerer, MD, PhD, professor, Breast Surgical Oncology at MD Anderson. "Our findings epitomize precision surgery in that we are specifically targeting the known disease and limiting the morbidity for our patients."